I know this isn't a strictly financial topic, but I can't resist writing about it from time to time. I often think about starting a third career trying to reform health care. Sometimes it is so embarrassing to be part of it. To make matters worse, both major political parties keep missing the forest for the trees. They focus so much on insurance reform that they forget that the problem isn't insurance, it's health care. I was reminded of this as I received my annual health insurance renewal in November of last year. We buy our health insurance on the open market and, as you might expect, receive no subsidy or employer assistance. Our premiums for 2018 are 13% higher than 2017 ($1345/month including dental if you care.) That's okay, our deductible went up even more – 16%. (Yes, that's sarcasm.) Our out of pocket max went up and our prescription coverage got worse to boot.
I understand why people are mad at the health insurance companies–the insurance companies are the ones you write the checks to. They're the face of a health care system with runaway costs. But they're only that. The face. The symptom, not the disease. The disease is that health care spending is way, way out of control. So naturally, the next place you look is to the providers of health care–the doctors and hospitals and drug companies. If they wouldn't charge so much for that health care, we wouldn't spend so much on it, right?
While health care reform is complex (and anyone who thinks the solution is simple doesn't understand the problem), only a small part of the problem lies with the insurance companies, the doctors, the hospitals, and the drug companies, who are really just doing what they are incentivized to do as any rational economist would expect. The main part of the problem, dear patient, lies with you. “What?! How can that be?”, you say to yourself. Let me explain, and when I get to the end, I think you'll agree that the patient himself shares a large part of the blame, if not all of it. The rest of this post will discuss the four keys to fixing the US health care system, but an almost subconscious theme of it will be that nobody here is innocent.
4 Keys to Fixing Healthcare
# 1 Effectiveness Transparency
Problem number one with our healthcare system is that we consume a whole lot of health care that doesn't do any good. Yup. That's right. There are a whole lot of health problems that modern Western medicine simply doesn't have a good answer for. Sometimes we can't even treat the symptoms effectively, must less cure it. A while back I wrote about the importance of understanding the concept of the Number Needed to Treat (NNT). That's the number of people who actually need to take a treatment or have a test done in order to help one person. For most medical therapies and tests, that number is NOT a single digit. That's right. You have to treat more than 10 people in order to help one of them. For some therapies, that number is over 100. Sometimes it is infinite. There is a number needed to harm (NNH) for every test and treatment too. And that number is often lower than the NNT.
What does that mean? That means 90% or more of the healthcare we engage in is unnecessary. People like to blame emergency departments for unnecessary care (even though emergency care is less than 2% of the healthcare dollar.) But the truth is that EVERYBODY is engaging in unnecessary care. Physicians, hospitals, drug companies, device companies. You name it. We're all guilty. But so are the patients. Since healthcare, like everything else in this country, is a business, you can't place all the blame on those who provide goods and services when you can't resist buying them. I see the silly stuff you're coming into the ED for. I can't imagine the silly stuff you're seeing neurology, orthopedics, gynecology, and your primary doctor for. And that doesn't include all the nonsense you're paying cash for outside the Western medical system. We have a serious problem with health care overconsumption. Take a look at your 85-year-old relative on 25 meds if you don't believe me. Think of all the appointments, tests, and pharmacy visits required to keep that list of medications going month after month after month, not to mention the hospitalizations required to treat the interactions.
Doctors and patients need to have A LOT more conversations about whether to do a test or treatment. About what the NNT and the NNH really are for each of them. For those things that we don't know how well they work, we need to focus our limited research dollars there.
But wait, there's more. We're spending a ton of money on stuff that is even LESS EFFECTIVE than western medicine. You think the data is bad on drugs and surgeries and x-rays? Wait until you see the data on chiropractic and essential oils.
For sure there are aspects of Western medicine that are incredibly effective and have helped us to reduce morbidity and mortality. But you might be surprised how few and far between super effective things like clean water, vaccines, insulin, seat belts, and surgery for necrotic bowel really are. Government, doctors, hospitals, and patients all have a role here in really looking at what is effective and what isn't. If we can simply drop the ineffective stuff and most of the barely effective stuff, we can dramatically decrease the cost of health care.
# 2 Price Transparency
Imagine going to a restaurant and ordering a meal off a menu without prices. You then walk out of the restaurant without paying any money. Six weeks later, the bill is sent to your “restaurant insurance” company. Six weeks after that, the insurance company sends you a bill for your portion of the meal. Crazy, right? You don't even remember what you ate 3 months ago. If we're going to have health care be a business in this country (and having worked in socialized medicine, I don't necessarily think that's a bad idea) you have to have a functioning market. And guess what you need for a functioning market? That's right. Prices. You need to know the price of stuff. Both patients and doctors. You want to bring down the cost of health care? You want to see what competition and a true market can do to reduce costs? Mandate that every health care provider in the country post its prices in the waiting room and on the internet.
Now I know it's complicated. You don't exactly know what a patient is going to need when they check in to the ED or show up in clinic. But you can post averages. You can post the price of common tests and treatments. You can post a sample bill for your most common complaints. As it is right now, even a savvy consumer (or a savvy doctor) has no idea what the price of anything is. Doctors, hospitals, pharmacies, and drug companies are all incentivized to make this as opaque as possible. Nobody is going to post their prices unless consumers (probably through their government) force them to do so. But you can't have a market without prices. And I'm not talking about chargemaster prices. I'm talking about the real prices. It's ridiculous that every patient has a different price list. It's amazing how much the price can come down when insurance is taken out of the equation. I drive by an outpatient plastic surgery center every day and they have a big flashing billboard- “Saline $4800, Silicone $5800.” LASIK surgery is similar. Concierge clinics have proven effective in some specialties, but surely we can come up with a system where we can have both insurance coverage AND price transparency.
# 3 Skin In the Game
The other factor required for a market solution to bring down health care costs is skin in the game. When you're spending someone else's money, you're far more likely to overspend. Too many health care consumers in our country don't have enough skin in the game. They're on Medicaid, or Medicare, or Tricare, or VA care, or a plan subsidized by their employer. Or perhaps most of the cost of it is covered by the taxpayer through PPACA tax subsidies.
My family buys our own health insurance on the open market, but we are a tiny minority- just 16%. It's not that I'm against insurance, even insurance run by the government. But people need a meaningful amount of skin in the game in order to have a functioning market. Even having to pay $100 for that MRI is going to make most people think twice about it. If Levaquin costs you $75 and Cipro costs you $4, you might rationally conclude that you'd rather take the whole family to the movies twice and have to take Cipro twice a day instead of Levaquin once a day. But if they're both $10 after the prescriptions get “run through insurance” what do you care? You don't.
I had a patient the other day who I shocked out of a-fib after he came off a cruise and flew across the country to see me. He didn't have health insurance because it was too expensive. Yes, that's right. He can afford a cruise and airfare, but not health insurance. I didn't entirely fault him. He had made a rational decision that he'd rather go on several awesome vacations a year than have health insurance. When people have skin in the game, they can make rational economic decisions. An MRI or a used car? Knee replacements or taking the extended family on a cruise to Alaska? An expensive arthritis drug or living in twice as nice of a house? Chronic suboxone treatment or a live-in masseuse for your fibromyalgia? You could do this all day, and when people do, they will spend less on health care.
This is actually the area where recent healthcare changes have had the most effect. This trend toward higher deductibles has made many of us reconsider how we want to spend our dollars. But there has to be a middle ground somewhere between $3 ER Medicaid co-pays and $8,000 annual deductibles.
# 4 Death Panels
There, I said it. I'm a huge fan of death panels. In fact, nearly everybody I know who works in health care is a fan of death panels. They get a bad rap, of course, but they exist all over the world. A death panel is simply a group of dispassionate professionals who look at various tests and treatments in various medical scenarios and decide whether they should be allowed or not. It breaks our hearts to hear “no more should be done,” especially when it's our beloved grandma on the vent or a 23 week million dollar preemie. We hear about the miracles and say “there is no price too high for life.” Well, guess what? That's not true. Want to know what a life is worth? Check out the latest round of malpractice awards. Most of our lives are worth less than policy limits (generally $1 Million.) And if the number needed to treat to put grandma on a vent for a month is 200, and it costs $100K, well, you can do the math. We're saying Grandma is worth way more than any reasonable jury would indicate.
“But we don't want to ration care,” you say. Don't kid yourself. We already ration care. We do it all the time. Usually by what type of insurance a patient has or how much money they have. What do you think insurance pre-qualification is all about? Do you really want the insurance company or your wallet functioning as your death panel rather than a committee of docs guided by the data? “I see everybody,” you say. Try calling your front desk sometime and pretend you're a patient without insurance and try to book an appointment. See how that goes.
The death panel could also get involved in malpractice situations. There are plenty of guidelines out there for doctors to follow, but there is no back-up for the doctor who does less (per the guidelines) and then suffers the inevitable bad outcome. She still gets drug through court for 5 years. It would be far better to have a “No-fault” system where those who are harmed are compensated whether there was an error or not and the frivolous 85% or so of lawsuits never get filed. And instead of having attorneys and courts police the medical profession, the death panel can do it. Everybody already hates them anyway.
While I'm on this rant, let's talk about the whole “healthcare is a right,” thing. What a ridiculous bit of poppycock. You can't go to the store and get food without having to pay, no matter how hungry you are. You can't go to a hotel and sleep in their beds without having to pay, no matter how tired you are. If we don't have a right to food or shelter, why would we have a right to healthcare? That doesn't mean that government doesn't have a responsibility to its least fortunate citizens to provide some basic level of necessary health care just like food and shelter. But doctors, hospitals, and pharma companies seem to only recognize one level of healthcare without regard to the patient's ability to pay. It sounds super noble, I know, but it becomes much less noble once you bankrupt the patient. “First do no harm” applies to their wallet too. The death panels can determine what that basic level of health care looks like, and if people want to get the deluxe version, they can go without $1,000 iPhones and cruises to get it.
Healthcare reform is a huge, complex problem. We're all part of it–government, healthcare providers, and patients. But if we want to bring down the cost, the best way to do so is to consume less healthcare. These four keys will help us to do that.
What do you think? Do you agree these are the four keys to bringing down the cost of healthcare? What would you add or take away? Comment below, but avoid inflammatory and ad hominem statements and references to political parties and figures if you wish your comment to still be there when you come back.
The price transparency concept would really be useful. I find even when you get a bill 3 months later it is too generic to interpret. As a patient it is maddening.
Death panels. Be careful of the premie example. I delivered a set of 23 week twins who are now in high school. They never had a NICU set back. They will be productive citizens. I agree with not resucitating some extreme premies or some congenital anomalies. I also think the role of at home hospice care should be encouraged and publicized. The best plan is to not bring some types of patients to the ER at all.
Number 5 would be tort reform!!!!!! It would be great if one did not have to order needless imaging and lab work to protect yourself.
Agree with all the above, but 100% agree with Number 5 as Tort reform. Defensive medicine raises cost. There are many others but if you have to narrow it down to 5 these are some good ones. Good luck fixing the system. Politicians and lobbying (including lobbying from doctors/hospitals) will prevent any reform from happening until the system collapses. Complete and total financial collapse of the system is the only thing that will eventually get it fixed…..and even then it will likely still suck. As you can probably tell, I’m not a real optimist about the situation.
I agree that tort reform needs to happen. I disagree that it would make for a major cost reduction. I think most docs practice defensive medicine, but not defensive medicine to keep from getting sued. The likelihood of getting sued is just too low and the likelihood of actually losing their own money is so low as to be negligible. They’re practicing defensive medicine in defense of their patient. They know they’re not perfect, they know they don’t know everything, they know diseases don’t always read the medical textbook, and they’d hate to miss something that might hurt their patient, especially when the patient really wants to do more testing anyway for whatever reason, whether logical or not. It’s customer service and a true desire not to hurt the patient far more often than it is actual “fear of a lawsuit.” I order “CYA tests” very rarely, and usually only when the patient tells me there is already a lawyer involved (auto accident type stuff).
I disagree. I think there is lots of CYA medicine being practiced if one looks for it.
I think there is a lot of CYA medicine practiced but it really isn’t for covering against law suits. I work in a tort reform state. The likelihood of being sued is relatively low and the payouts are pretty small compared to a state like Florida. The docs here perform CYA medicine because they are afraid of missing something and because they don’t want to end up in front of the peer review committee or the medical board risking losing their privileges or their license. CYA medicine still exists in my state despite the tort reform.
Patient, physician, hospital, insurance company ALL need to have an incentive to reduce costs.
Healthcare as a right and subsidies, CYA procedures and tests, facility utilization and financial performance, higher premiums and deductibles are NOT aligned to reduce costs.
The system is set up to shift costs and risk to a different party.
The bottom 10% can’t afford anything, thus it’s difficult to prevent excessive and inefficient use of resources.
The top 10% can afford anything, thus it’s elective. The middle 80% are stuck with difficult costs in a system that the competing parties are professionals, they are the amateurs.
The incentives aren’t going to work unless it’s in the physician, hospital and insurance company’s benefit as well.
The premies might be productive citizens, but will never recoup the $1M each it likely cost to get them there.
Medical resources are finite. It’s true in all professions, but medicine is one area where it’s largely ignored in the conversation.
How many other people and conditions could those same resources have treated?
You’ve done it again, Jim. Saying stuff that other people are afraid to say. I finally retired from health care after 25 years because I was embarrassed to be a part of the “system” any longer. Yes, the “system” is screwed up. I can’t tell you how many strategy sessions I’ve sat through trying to figure out how to increase revenue (not patient care). But you are the first person I’ve heard publicly state the REAL problem…….we consume WAY too much healthcare. Just like most other aspects of our consumer driven society, Americans can’t help themselves. And the “system” does its best to fan the flames of consumerism. Just like any other industry. The public, in general, has been convinced that they need to see those 5 different docs and take those 8 different drugs every day to stay healthy. Disgusting. Want health care reform? I completely agree that it begins with each individual.
One of your best ever, Doc!
Medicaid reform is also a big component and keeps getting bigger. People are told by the welfare office to quit their jobs and go on welfare all the time, as they will do better economically. As a pediatric subspecialist, I am appalled at the number of abused and neglected kids I see regularly. Some parents have more kids to get more money, and then the kids are neglected because the parents really want the money not the kids. When CPS comes to take them, they get upset because when the kids are gone the money goes away. If the system would only pay for one child per family to be on the welfare system, I suspect there would be a lot less abuse and neglect. The parents who only want the money from welfare would stop having more than one child. The people who want several kids can have them; they just have to pay for them. This is not all directly related to health care, but it is part of the bigger picture of entitlement. I can tell you that my Medicaid parents are the most demanding, difficult parents I have, which is why I have all but stopped seeing them.
Really love these points, and I agree with Hatton1 that price transpancy would likely have the greatest effect. Essentially would have the market determine the price of a medical intervention as consumers would frequent the most cost effective option.
Another huge factor that could drive Healthcare costs down is the ability to drop so many unnecessary things used for “defensive medicine.” A lot of labs/imaging studies/procedures are done mainly to CYA from the risk of that one in a million condition that may have similar presenting symptoms. If we weren’t worried about the threat of malpractice lawsuits constantly over our practice, we could actually use our judgment to offer appropriate treatment without superfluous tests to exclude every badness under the sun.
I love your example of going to the restaurant without knowing the cost of the meal to only find out several months later. Really drove home that point.
I agree with the fact that a big problem is the CYA problems in Healthcare. Most people trust in their physicians decades worth of education to make the decisions for them in regards to their care. If physicians were not incentivized to CYA and also to do testing and procedures to make more money for themselves the healthcare costs would come down substantially. Patients should be sent away requesting useless tests and procedures. No transparency needed if physicians could just make the right decisions and do the highest good for all. IMHO this is by far the biggest problem with costs!
I cannot tell you how many times I’ve gone in to do a pre-op on a child for dental surgery….whose parents have neglected brushing the kid’s teeth…and are on medicaid.
But guess what? Kid has an iPad, parents have iPhones, wearing designer label clothes. If there was a connection between making your kid brush his teeth, or having to pay for dental care….you’d do the toothbrush.
One of my most vivid memories from back in my OB days, was walking to the office noticing a nice new pickup truck in the parking lot. Had the “temp tag” from the dealer, with the name of the buyer clearly written.
It was my “new OB” patient for the morning….and yep, you guessed it….on medicaid….I’m doing her OB care for 25% of my normal fee, paying for that with tax money…but she has the money to buy a new truck.
Like you said…nothing else is “free”….food, gas for your car, shelter. It’s the “elephant in the room” that few people want to talk about.
Preach on.
I think you are missing a huge aspect in your reasoning. Medicine is not focused on prevention. We are only problem based care. It is good that you point out that many of our treatments are ineffective. Something we barely get training on in medical school is nutrition and the importance of physical activity. Many of the patients that are on multiple medications have yet to be educated on or incorporate the two biggest things that can help their health – diet and exercise. A major shift needs to occur in medicine to be focusing on prevention and the importance of diet and exercise as treatment for many of the most common and expensive ailments we deal with today. We also need to put some of the ownership of incorporating these essential elements onto the patient as well to make the change.
I agree. Eat to Live by Dr Fuhrman (or something similar) should be required reading in high school.
Yes, it’s one thing to fish all the people out of the river. It’s another thing to help prevent them from falling in in the first place (but that doesn’t pay any money). Here’s a news flash: Behavior changes might help https://www.reuters.com/article/us-health-obesity/u-s-doctors-recommend-behavior-changes-to-prevent-obesity-related-health-issues-idUSKCN1LY2UP
Wide swaths of physicians are obese and overweight themselves, so lack authenticity for behavioral changes.
At least most physicians have quit smoking.
I hear this a lot, and I don’t disagree that nutrition and exercise are important. I do disagree with the idea that most patients don’t already know that.
So patients know it, but don’t seem to care. I say “seem to care,” because I don’t think anyone wants to have foot amputations and heart disease from diabetes. It’s human nature to discount future consequences for current desires. Sounds like a lot of opportunities to learn more about change management and behavioral economics here.
My wife (OBGYN) counsels patients who are overweight. Living in the South, she sees plenty. She’s had patients tell her “you’re the first to really talk to me about this” and also scream and yell at her for being ‘rude’ or ‘disrespectful’. In any case, it’s difficult for a doctor to make a significant impact on behavioral patterns in a 15 minute annual appointment. Programs are popping up (via wellness companies, some insurance companies) that post dieticians in grocery stores, to physically walk through the store with the patient/member and talk them through healthy shopping and cooking.
Your local WalMart already has a restaurant, jewelry store, salon, pharmacy, optometrist, auto care center, and maybe some have medical clinics. I’m sure Target will start this with their CVS Pharmacy link. Seems like a good idea to have someone onsite to help people shop.
Dieting and exercising regularly is hard. These same patients can’t manage to regularly take their diuretic pills lying on the kitchen counter and wind up hospitalized from it. Suggesting a lack of education keeps them off the treadmill seems ludicrous to me.
Patients don’t care as their immediate desires are more important than their health. It is why you see smokers continue to smoke while needing a foot amputation or living on oxygen. It is why diabetics continue to get heavier and heavier despite infections and kidney disease. People care more about the now than the future.
Great post Jim. Agree with most of what was written.
With regards to behavior: The government should require a nudge unit to promote positive behavioral changes in Medicaid recipients. That would have a pretty decent bang for the buck!
Dont mean to come off brash but I’ve seen and dealt with tons of online Gurus spouting this nonsense.
You dont need any, let alone more than we get training/education in diet/nutrition/exercise, anyone over the age of 15 should know the basics pretty well.
The same thing goes for the rest of it as it focuses on prevention/etc….Lots of medicine does do this, and the reason it doesnt “do more” isnt because you dont get paid, because we’ve done more and more. The reason it doesnt work is because it relies on the end user to do the work and change.
Pts have skin in the game, they’re the ones that get the disease, the morbidity and early mortality associated with it.
Everyone needs to accept their own responsibility. Its not medicines fault the diabetic wont stop crushing that box of Krispy Kreme and wont get off the couch, and its beyond absurd to suggest just focusing on telling them the blatantly obvious changes things. Its not human nature.
Physicians need to stop taking, and getting blamed for pts decisions. I tell my staff that 95+% of post op care is keeping pts from harming themselves, and its true at least in my field with healthy pts and elective procedures. The great majority of issues arise from pts just not paying attention but more often just openly disregarding instructions (eg, drinking 2 days postop and swimming, dancing, etc….not an uncommon problem for me).
Wow, wonderful post! YES we need to STOP doing stuff that does NOT help. As an Anesthesiologist i sometimes feel aweful because I am an “accomplice “. We (I) am totally incentivized to “not rock the boat” and seeing people undergo procedures that (in my opinion, sometimes wrong) are ulikely to help and likely to cause pain, suffering, prolong the inevitable while depleting savings…….well, that is the least favorite part of my job. It is one reason I will retire early and one of my greatest sources of burnout. I know it is complicated but currently it is broken and unsustainable. Death panels, YES! Panels to decide if major surgery is likely to help, YES, Information is power! Data = evidence based medicine with info and options presented by unbiased professionals on panels and make doctors/hospitals/providers info available so people know, for example, Anesthesiologist A has had zero failed airways resulting in a sat less than 10% below baseline in the last 5 years and she takes on average 18 minutes a cental line and has had 14 /1000 failed iv sticks in the last 3 years, and this is above average (she is good), or Surgeon X takes 3 times the national average to do a straight forward CABG and his length of stay is 3 weeks longer and his icu stay is …..infection rate is….and the panel gives him a C, and none of them would let him operate on their cat. Anyway, would that have problems, sure, would it be perfect, No, but we need to give patients data. Some surgeons are GREAT! we should reward them!
You’ve had a major impact into the financial lives of thousands of high income professionals. If you want to have a major impact on the entire country, this should be your next book. Or you should run for public office and try to change this.
After watching the hearings this weekend, there is no way in I’ll ever be a politician or a judge. Too much stupid (but legal) stuff in high school.
that’s why we will never have smart politicians
#dahle2020
OMG yes!
Good ideas, but they require an open, transparent market for healthcare which is impossible to implement because the real problem is that it is impossible to have a real health care market when the government runs so much of the health care system (Medicare, Medicaid, VA). If we actually had a real market for health care all the other things we need to make it work smoothly and efficiently would pretty much arrange themselves spontaneously (the invisible hand). Medicare and Medicaid price schedules, rules, and regulations all work against an effective marketplace for a plurality of the population and probably a majority of health care spending, and these obstacles have outsized effects on the health insurance market (e.g., all the plans that have their fee schedules set as percentages of Medicare).
Also, as per the death panel idea, once the government gets involved all decisions eventually become political ones, not rational ones.
That’s the major problem. Another significant problem preventing transparency and skin in the game is the insurance system, which creates a “triangle of obscurity” by making health care into an absurd three-way transaction that nobody can figure out. Every health care interaction has a patient-physician component, a patient-insurance company component, and a physician-insurance company component. Transparency is prevented by the fact that each party is left out of the loop in one aspect of the transaction. In a more rational system, there would be a transparent financial transaction between the physician and the patient and another transparent transaction between the patient and the insurance company. In that scenario, both the physician and the insurance company would be incentivized to best accommodate the patient or the patient would move on to a more accommodative insurance or healthcare provider.
A real effective health care system would have minimal government involvement (and the government involvement that there was would be mostly at the local and state level), a low-level “safety net” program offering a basic set of health care services to all comers that would be subsidized for people unable to afford care, and health insurance only available after-tax with direct payment of the full premium by the insured/patient (this doesn’t mean that you can’t get your insurance through work, you just need to pay the full premium out of your after-tax salary). If those were the facts on the ground with regard to health care, a real, transparent marketplace that would drive prices down to reasonable levels would emerge on its own (of course, physician compensation would also decrease substantially, partly because, despite the efforts of WCI, we are mostly lousy businesspeople and negotiators). Consideration might be given to a program to provide universal coverage to children (maybe including pregnancy as well) in order to provide optimal care to the next generation (Microcare?), although any such program would undoubtedly end up being dysfunctional and wasteful like all public programs end up.
I’m so happy to see this debate, and I’m glad it’s on a forum like this. Unfortunately, Pevend, I believe is right : “Also, as per the death panel idea, once the government gets involved all decisions eventually become political ones, not rational ones”. I agree the consumer is to blame as well. I’ve heard family and friends lament about poor outcomes and lawsuits for preventable diseases. It’s a very complex problem that unfortunately will most likely won’t change until the straw breaks the camels back.
Price transparency and skin in the game are related and, against all intuition, the empirical evidence for their effectiveness at controlling costs does not look good. The elephant in the room is the fact that patients don’t have the slightly clue as to how to assess quality of care beyond the physician’s attentiveness, which very often involves overtreatment. It’s impossible to shop for what you don’t know you need. I can’t think of a solution that doesn’t involve middlemen. All roads lead to death panels.
A big reason we are in this mess is the general attitude of Americans. We see it in healthcare, but it exist everywhere. Americans are entitled. We want it and we want it now. We want to see a doctor now, we want his/her attention for as long as we want and we want the treatments we want. We are increasingly measuring a doctor’s worth by how happy patients are rather than objective measures such as outcomes of treatment.
In Canada people wait for months if not years for some elective procedures (sinus surgery). Imagine telling an American that. However the same outraged person will loudly vocalize that Canada is their proof thar nationalized healthcare works.
Quite simply we are screwed in this country with healthcare until we change the attitude of Americans. People have to accept no as an answer. No to some end of life care, no to referrals to specialist, no to some procedures. How do we do this? Honestly I don’t believe we can. Americans are too entitled. You institute your death panels, judge doctors not based on happy patients, but rather results and start telling people no on elective procedures and riots will ensue. I agree with you, but i dont believe in anyones ability to change this attitude.
Love it! I found it extremely fascinating how aware patients in a developing country (Belize) are of a) their medical conditions b) their test results c) possible alternatives because they pay out of pocket for everything! Even in a shanty, a patient will have their medical data carefully stored because each evaluation was an opportunity cost.
It’s a minor point, but how about achieving economies of scale and quality by nationalizing the credentialing process, licensure process, and having a nationalized EMR/imaging system? Why does every hospital have to be its own fiefdom and do its own background checks? We already have a national medical licensure examination; why not extend that one step further and just have one medical license?! And how much money is wasted repeating labs and imaging, because the outside hospital’s records are incomplete or the CD won’t load/can’t be found/etc??
Small stuff, but each little bit counts.
The only problem with a national EMR is privacy, but that’s becoming less and less of an issue all the time.
If the national EMR is anything like what the VA uses then please keep me out of it.
The VA is moving to Cerner/CIS/Powerchart whenever they get around to finally updating
Likely competition and antitrust had a lot to do with it. Hard to act as if we actually have privacy with all these Alexas and people on facebook.
Price transparency and a good system is key. I dont think you’ll get anywhere with pts, the information asymmetry is simply too great and the way to solve that is by having a better system designed with that knowledge in mind. People adapt to the system they have, its a bit of a logical/rational response to that.
We’re a very rich country, we can very well afford to have excellent health care for all, but would come with trade offs of course. We dont seem (by we I mean those that make the rules) willing to accept them just yet.
Bravo!
All great ideas.
However, I wonder if some powerful political-action committees would fight against this?
With the exception of the death panels, which are completely logical and necessary but scary for some, I think all people would get behind these ideas.
I’m with you on 1-3. NNT/NNH are part of my core discussion with patients/parents a lot of the time, though they don’t get calculated in studies very often so are hard to find. I’m sure during your military career you’ve had the same conversation we do every night shift when the ‘sick call rangers’ wander in pre-PT with a sore throat asking for quarters…”if we just charged $5-$10 for an ED visit and left pcm as free, they wouldn’t do this.”
The “death panels” are my issue, at least partially because of the (admit it, click-baitey) name. What scope do they actually have? Obviously not every decision, that’d be medicine by committee which would take even longer to get seen. If only extremis decisions, then what’s the use since the patient will be dead before the decision? If a gray zone (obviously), then where are the lines? Voluntary only?
What is their obligation – individual or society? Studies show treatment X has a NNT of 200 in a general population and thus is not allowed, but patient Y has had it before and it worked for her…do we do it? Another example – colleague of mine has MG and has already had multiple millions of dollars of care to stay alive/functional. Do we continue her monthly expensive infusions? Does the fact that she’s a physician and could reasonably be expected in her career to be able to put that back into society matter?
Finally, what expectation is there that a bureaucratic body (government or private) will be on the bleeding edge of technology for every specialty? Eventually the committee is made up of humans and they are weak and busy and, “well I saw this one study that antivenin really isn’t helpful in copperheads and this guy was bit by a mojave rattlesnake, that’s a crotalid just like the copperheads, so obviously antivenin isn’t a reasonable expense here.” To avoid people having to be intellectually pushed out of their lane, you would need an ever expanding number of docs to sit on these panels (reducing their clinical time). Even then, you could wind up with surgeons arguing for appendectomy and internists for antibiotics with a patient’s fate determined by strength of personality on a committee.
Not to say that doesn’t already happen via the P&T committee anyway. Or that any of the above are insurmountable. Just…concerns.
It’s complicated for sure. Doesn’t mean we shouldn’t work on it.
Amazing timing. This article just came up on by computer http://www.arstechnica.com/science/2018/09/after-century-of-removing-appendixes-docs-find-antibiotics-can-be-enough/ .
The basis for the article is ““This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis,” the authors conclude.
The finding suggests that many appendicitis patients could be spared the risks of surgical procedures, such as infections. They may also be able to save money by not needing such an invasive procedure (although the study didn’t compare costs), and they could reap the benefits of shorter treatment and recovery times. Researchers will have to collect more data to back up those benefits, though.”
Yea, you also have to consider the recurrence rate, the cost of hospitalization to observe while giving antibiotics rather than a quick outpatient procedure, the risks of antibiotics etc. It’s complicated, but it would be nice if it were more of an option.
Anyone spending some time on surgical rotations knew this would come (at least it was obvious to me, what was so different about appe’s?), but it will require a lot of work to find out who, when, where, etc…its best employed. Also, appe’s are fast, safe, and easy overall.
Probably the best interim thing would be to bridge them with antibiotics, etc….so they can be done in regular hours, and maybe a cleaner overall surgical procedure. Decreasing complications, etc…
go to a chiropractor or PT and they will keep you coming as long as benefits are being paid
Sad to see doc’s income decline while CEOS are garnering monstrous salaries
Ad hominem comment not appreciated. We are very proud of our EFFECTIVE chiropractic clinic, where prices are transparent and patients are educated on true nutrition and exercise, along with mindfulness practices to reduce stress with the goal to teach them how to self-maintain their health. Our practice is 80% cash-based. Care is not based on insurance reimbursement and to blanket us with that accusation is offensive.
I’m sorry to interject this in a good financial discussion, but, I have talked to chiropractors who believe they can treat Strep throat with chiropractics. I had a patient tell me their chiropractor found a “hole in their baby’s head” that their doctor missed and successfully treated it with a cream they sold them. (Yes, it was one of the fontenelles). I also once read a CT scan on a patient with low back pain who had been seeing his chiropractor for a long time with no success. There was a massive destructive malignancy destroying L5. I wondered how a chiropractor can feel subtle “subluxations” of the spine but not a huge protruding malignancy!
I know that some patients swear by their chiropractors but a lot of us in traditional medicine question the practice of many. This does add to the cost of medicine.
There are quacks in every specialty and every profession. Don’t paint us all with the same brush, as we would not paint DOs/MDs that way, despite the many and diverse horror stories our patients tell us, and which I won’t repeat here. We refer to MDs when indicated, including orthos, neurologists, cardiologists, and an oncologist once for something identified in our clinic but missed for years by the patient’s MDs.
I agree that there are quacks in traditional medicine but the difference is that traditional medicine uses a basis of education from scientific method, peer reviewed and critiqued methods for care. I don’t think that chiropractic care is based on the same premise. I think the premise is quackery. Here is one example of many of what I mean:
https://sciencebasedmedicine.org/top-10-chiropractic-studies-of-2013/
Recently saw a study that compared mindfulness to watching television and saw no significant difference. Let’s not get into the “data” on chiropractic manipulations.
This article is very brave and I bet many outside our group would have a highly emotional and negative reaction to the logic in it. Now I don’t call them “death panels” but rather scientific effectiveness panels. I would only add on additional comment, the process of delivering health care is full of waste and errors. When a hospital has a quality officer it is generally a doctor who is not really highly trained on quality improvement activities or process. The leave their highest value where they are very competent (doing Medical care) to be a manager of a process where they are not that competent. I look at our system from a macro level where if we want a reduction in the resources to be applied to health care that requires either fewer resources or paying less for them, or better a combination of both. What doctors want to either work much more for the same compensation, or have their compensation reduced? What other employees in the health care system would want or allow that? In addition the insurance system needs reform, why do providers have to register themselves with individual companies or plans? Why not a single database for that.
Might as well call them death panels. Your opponents will.
Pretty close to my opinion; you’re preaching to the choir.
My initial response was that you should clean up the jargon and submit this as an op-ed … but then I wonder “what’s the point?” … I am truly hopeless that anything will ever change.
Preach on Dr. Dahle!
I love the idea that health insurance does not equal health care.
The biggest thing I’ve seen lately to try to combat some of those points is the Direct Primary Care Movement focusing on Transparency and Accessibility, which ties in to your “Skin in the Game” comment.
Urgent Cares were designed to offload unnecessary ER visits, but now people are using Urgent cares for stuffy noses that they normally wouldn’t have gone to the ER for, or using them for Primary Care needs that isn’t the right place for them.
Specialists are getting over-abused because there’s not enough time to talk with the PCP through their issues.
I recently had a patient I diagnosed with Testicular CA – No insurance – I was able to get Ultrasound ($100) SURGERY ($4500), Tumor Markers ($100) AND CT Abd Pelvis with contrast ($300)….all done in less than a week…just because I asked “HOW MUCH” – We ran him through a quick hypothetical ACA plan and insurance was going to bill over $25,000! Just saved $20,000 in “Health Care Costs” because we asked a question.
We need to drop an atomic bomb on health insurance as it stands currently!
JAMA had a recent article regarding the cost of medicine in the US versus other industrialized countries. The largest difference in cost lay not in physician pay compared to our international colleagues but largely is the absurd level of management pay and drug costs. We might be able to justify a certain portion of the drug costs related to R&D, but the pay of managers and C suite executives is unjustifiable.
I cannot tell you how many patients get upset with me that I’m not ordering another OB ultrasound, after a normal anatomy scan and a totally uncomplicated pregnancy. They think they have the right to just request one to see the baby, or get an estimated weight (which is NOT very accurate and only indicated for certain pregnancy complications). And yet, I have administrators breathing down my neck about the importance of patient f-ing satisfaction.
I also love how increasing healthcare costs (and maternal mortality) are supposedly all my fault, despite the average age, BMI, and list of medical conditions per OB patient only getting higher and higher.
I agree that patients have a huge responsibility in limiting excess care. However, there has to be a middle ground. Right now I have a pt with CIN3 who keeps cancelling her LEEP because she can’t afford the copay. I’ll probably see her in 10 years with cancer, which won’t exactly be cheaper. (NNT for LEEP to prevent cancer is 3, BTW)
Great points Liz!!!
Lay people like to spout statistics about infant mortality in the US compared with Europe. The underlying accusation is always that OBs are paid too much and are less effective. After explaining how obesity and teen pregnancy rates are much higher here, I then need to explain why those are associated with poorer outcomes. I’m not an OB, but can appreciate the difficulty of getting a macrosomic baby out of a 15 year old. Not having any knowledge of the subject sure doesn’t preclude having an opinion on it.
IIRC, there is also a big difference in how “infant mortality” is calculated. (it’s been a while since I looked at this)…
In the US, beyond 20 weeks gestation, it’s considered a “birth”, whereas in other countries it’s counted at 24 or 26 weeks…prior to that it’s a “miscarriage”.
“how” a rate is calculated has to be the same for the statistic to be valid. Our US population is much different than a Scandinavian country population.
Well said. I haven’t read up on this but I’m sure this can carry over to many other aspects of country healthcare comparisons. I always read about poor US healthcare quality, cost, etc. and I wonder if it’s truly an apples-to-apples comparison. I have a sneaking suspicion that it’s not.
Very bold article — to be honest, I expected the comments section to be a firestorm (and probably would be if 99% of the readers weren’t also physicians). Lots of interesting thoughts.
1) You make a very strong argument re: “Death panels” … but there is no hope this concept will ever accepted in the U.S. by that moniker. Far too easy for politicians and activist groups to harp on and use for extreme hyperbole.
2) As the first commenter mentioned, I would be careful grouping in the extreme preterm infant with the other examples you listed that would benefit from death panels. While long-term outcomes among all comers at 23 weeks may be poor on average, 23 week infants delivered at a tertiary care center with a high level NICU who receive excellent resuscitation and care can have excellent outcomes (obviously there are a lot of mitigating factors that come into play — maternal prenatal care, size of baby at birth, gender, etc). As a neonatologist, on multiple occasions I’ve watched babies who even I wondered whether resuscitating them was ethical eventually go home with their parents to live relatively normal lives.
Extreme preemies get a bad rap b/c the only ones that are visible in other fields of medicine (ED, PICU, peds wards, high-risk specialty clinics, etc.) are the high utilizers who had worse outcomes — the vast majority who do very well aren’t nearly as visible.
Give me the access to the insurance discounted prices, and I won’t need health insurance anymore! Doctors are not allowed according to the contracts with the insurance companies, to give heavily discounts to patients without insurance. They must charge at least 5x the insurance discounted price. MRI, X-Rays..etc are charging 10x the insurance rates. That is the problem. So I disagree with the article, yes these points are good ones and can reduce the cost a bit, but the main issue is the 3rd man. Always look for the broker.
anyone ever go for PT with less than the maximum allowed visits
chiro adjustments? 30 seconds max look at the charges
$1500 retail fee for KNEE INJECTION!!
BUT by cardio surgeon got paid the same fee in 2015 that he got in 1981 for 8 hr valve surgery
BTW-Dr Stelzer Mt Sinai NYC
In our chiropractic clinic, first visit = 45 minutes. Subsequent visits 15-30 minutes, one on one with the doctor. Hands on.